Intrahepatic bile duct stones are clinically common. For complex left intrahepatic bile duct stones, resection of the diseased liver segment is the most effective treatment. The First Hospital of Wenzhou Medical College started to treat intrahepatic bile duct stones by complete laparoscopic left hepatic lobectomy in November 2003, and 24 cases have been successfully performed until October 2008. In order to analyze the treatment effect, the author randomly selected the same number of cases as laparoscopic hepatectomy in each year as a control study among patients who underwent traditional open left hepatic lobectomy during the same period. This is reported as follows. Data and methods 1. General data: There were 24 cases in the laparoscopic group, 7 males and 17 females; age ranged from 27 to 63 years, with an average of 48 years. There were 18 cases of left intrahepatic bile duct stones, 6 cases of left and right intrahepatic bile duct stones, 10 cases of gallbladder stones and 11 cases of common bile duct stones. 5 of the 24 cases had mild jaundice. There were 19 cases of Child A liver function and 5 cases of Child B. There was a history of one biliary tract surgery in one case. In the open group, there were 24 cases, 6 males and 18 females, aged 35-68 years, with an average age of 50 years. There were 16 cases of left intrahepatic bile duct stones, 8 cases of left and right intrahepatic bile duct stones, 8 cases of gallbladder stones and 9 cases of common bile duct stones. Six of them had mild jaundice. There were 18 cases of Child A liver function and 6 cases of Child B. There was one case with a history of primary biliary surgery and one case with a history of secondary biliary surgery. 2. Surgical method: general anesthesia with tracheal intubation was performed for the laparoscopic group. The patient was placed in the supine position with the head slightly elevated, and a small incision of about 10 mm in length was made at the inferior umbilical rim to establish a. 2 pneumoperitoneum with an intra-abdominal pressure of 14 mm Hg (1 mm Hg=O.133 kPa). After insertion of a 30-degree laparoscope, a 12 mm trocar was placed under the subclavian process and a 5 mm trocar was placed under the left midclavian rib margin and a 5 mm trocar was placed under the right midclavian rib margin under direct vision. the circular hepatic ligament and the left deltoid ligament were cut with an ultrasonic knife (Johnson & Johnson, USA), and the sagittal dissection was performed to isolate the arteriovenous vein of the left outer lobe of the liver to be resected, and the bile duct was closed with an absorbable clip and left unclamped. The trunk or branches of the left hepatic vein were carefully isolated and clamped, appropriately away from the second hepatic hilar. Cut and dissociate the liver tissue with ultrasonic knife on the left side of the hepatic round ligament, and for the thicker vessels in the hepatic section, separate them clearly and then clip them directly with titanium clips. The dilated intrahepatic bile duct in the left hepatic section was opened, the common bile duct was incised longitudinally, and the bile duct was explored and the stone was removed using a choledochoscope (()lympus company). The gallbladder was excised. The left hepatic duct section was closed with continuous or interrupted sutures with 3 one o vicryl sutures, and the tightness of the sutures was judged by water injection through the T-tube, and the liver wound stump was sprayed with fibrin gel. The resected liver segments and other specimen bags were removed from the slightly enlarged incision. Drainage tubes were placed in each of the left hepatic section and the hepatic hilum. In the open group, patients were placed in the supine position after general anesthesia, and the gallbladder was routinely removed through the right oblique rib margin incision or the right rectus abdominis incision, the common bile duct was incised to explore and remove the stone, the left hepatic outer lobe was resected, the T-tube was drained, and the drainage tube was placed.3. Statistical methods: sPSs 12.O statistical software was applied. The £ test was used for the measurement data, and the Z2 test was used for the count data. RESULTS All 24 cases in the laparoscopic group completed the operation successfully. Laparoscopic left extrahepatic lobectomy plus cholecystectomy for common bile duct exploration and stone extraction was performed in 17 cases, including 5 cases with stage I suture of common bile duct and 12 cases with T-tube drainage; 5 cases with left extrahepatic lobectomy plus cholecystectomy; 1 case each with left extrahepatic lobectomy plus cholecystectomy for stone extraction with T-tube drainage and left extrahepatic lobectomy. All patients underwent laparoscopic choledochoscopic bile duct exploration or lithotripsy during surgery. Among the 24 patients in the open group, 20 patients underwent left lobectomy plus cholecystectomy with choledochotomy to retrieve stones, including 2 cases with stage I suture of the common bile duct and 18 cases with T-tube drainage; 3 cases with left lobectomy plus choledochotomy with T-tube drainage; and 1 case with left lobectomy plus cholecystectomy. Intraoperative choledochoscopic bile duct exploration or lithotripsy was performed in 12 cases. All cases were confirmed to have intrahepatic bile duct stones, dilated left extrahepatic lobe bile duct, chronic inflammation and fibrosis by surgery and pathological examination. There was no difference in age, gender, distribution of intrahepatic bile duct stones and liver function classification between the laparoscopic and open groups of patients. The mean operative time was longer in the laparoscopic group than in the open group [(162 soil 42) min versus (135±37) min, f=2.368, Po.05]. No blood was transfused in the laparoscopic group, and 2 units of concentrated red blood cells were transfused in one case in the open group. Two cases of postoperative bile leak occurred in the laparoscopic group, which stopped on their own at 3 and 5 d postoperatively, respectively; one case of pleural effusion occurred, which subsided after thoracentesis and aspiration; and three cases of small intrahepatic bile duct stones remained. In the open group, one case of peritoneal fluid infection, one case of liver abscess, one case of incisional infection and two cases of intrahepatic bile duct stone residue occurred after surgery. The difference in the incidence of postoperative complications between the two groups was not statistically significant (25.O% versus 20.8%, z2=O.123, P>0.05). The mean postoperative hospital stay was (6.9±1.9)d and (10.5±2.4)d in the laparoscopic and open groups, respectively, with a significant difference (£ I 3.043, P<0.01). There was a transient increase in serum transaminases in both groups after surgery, and the jaundice subsided at discharge. There were no perioperative deaths in either group. In the laparoscopic group, 13 cases were discharged with T-tubes, 10 cases were discharged 28-35 d postoperatively, and 3 cases were discharged 42-60 d postoperatively after choledochoscopic removal of residual bile duct stones. In the open group, 21 cases were discharged with T-tube, 19 cases were extubated 28-40 d postoperatively, and 2 cases were extubated 50 d postoperatively after choledochoscopic removal of residual biliary stones. 42 cases (87.5%) were followed up, 22 cases in the laparoscopic group and 20 cases in the open group, and the follow-up time ranged from 2 to 48 months (mean 16 months). Discussion With the rapid development of laparoscopic technology, the technique of laparoscopic liver resection has also been improved. Laparoscopic surgery has evolved from resection of benign tumors at the liver margin to resection of benign and malignant tumors of the liver and regular resection of liver segments for metastases, but the selection of cases and technical requirements are very high. Those with lesions located in Couinaud II, III, IVa, V and VI segments are the best indications for laparoscopic liver resection, in which regular resection of the left outer lobe of the liver is expected to be the gold standard for laparoscopic liver resection L1'2]. The author combined with laparoscopic cholangioscopic techniques, and used laparoscopy to perform regular left hepatic lobectomy for intra- and extrahepatic bile duct stones with success, providing another new option for the treatment of hepatobiliary stones. Comprehensive literature reports that laparoscopic hepatectomy is comparable to open hepatectomy in terms of bleeding, transfusion rate, complication rate, and morbidity and mortality rate; it is significantly better than open hepatectomy in terms of time to exhaustion and feeding, analgesic use, hospital stay, return to work time, and satisfaction; however, its operation time is slightly longer and the operation cost is higher. The author's study showed that in the treatment of intrahepatic bile duct stones, there was no statistically significant difference in the mean intraoperative bleeding and postoperative complication rates, although the mean operative time was longer in the laparoscopic group compared with the open group. The mean postoperative hospital stay was significantly shorter in the laparoscopic group than in the open group, which may be related to the minimally invasive advantages of small incision, mild postoperative traumatic inflammatory response, and less interference with immune function in the laparoscopic group. Moreover, the recurrence rate of medium- and long-term bile duct stones was similar in both groups of patients. How to prevent intraoperative bleeding, control bleeding and reduce bleeding is the key to successful surgery and good postoperative recovery of patients, which is also the meaning of laparoscopic "minimally invasive". The author's experience is as follows: (1) Adequate preoperative preparation should be done for each patient. Patients with good liver function and no coagulation abnormalities should be selected for surgery. The distribution, site, size and morphology of the liver of the stone should be determined preoperatively by ultrasound, CT or MRCP examination. Stones confined to the left outer lobe of the liver are most desirable and can be accompanied by common bile duct stones and gallbladder stones. (2) The surgeon should be well educated in traditional liver surgery and skilled in laparoscopic techniques, and should operate with care and patience. Excellent surgical instruments, such as ultrasonic hemostats, vascular closures and other hemostatic cross-sectional devices should be equipped. (3) Careful laparoscopic separation and clamping of the left outer hepatic lobe artery and portal vein branches, respectively, as well as the trunk or branches of the left hepatic vein, is a key step for successful surgery. (4) Dissection of liver parenchyma is the main step of liver resection surgery. Cutting and dissection of liver tissue with ultrasonic knife has the advantages of less tissue damage, less bleeding and facilitates exposure of intrahepatic ducts. (5) Intraoperative laparoscopic choledochoscopic stone extraction is beneficial to the removal of bile duct stones inside and outside the liver. In conclusion, laparoscopic left extrahepatic lobectomy with intraoperative and postoperative choledochoscopic stone extraction can effectively treat complex left-sided intrahepatic bile duct stones. Laparoscopic surgery is not only safe, with efficacy comparable to that of traditional surgery, but also has minimally invasive advantages such as less surgical trauma, less postoperative pain, and faster recovery, which is worth promoting the application.